Podcast: Lung cancer research and clinical trials
Lung Cancer Treatment
At MD Anderson, some of the nation’s top lung specialists focus their extraordinary expertise on you. We customize your treatment to deliver the most advanced, effective and least invasive treatments available for lung cancer. And because your peace of mind is important to us, we specialize in techniques and therapies than can help preserve lung function and quality of life
We’re constantly researching safer and more effective treatments for lung cancer with fewer side effects. We are proud to be one of the few cancer centers in the nation to house a prestigious federally funded lung cancer SPORE (Specialized Program of Research Excellence) program. This leads to a large number of active clinical trials at MD Anderson and ensures that our patients have access to some of the most cutting-edge therapy anywhere in the world.
If you are diagnosed with lung cancer, your doctor will discuss the best options to treat it. This depends on several factors, including the stage and type of lung cancer; other lung problems, such as emphysema or chronic bronchitis; other prior or current medical conditions; and possible side effects of treatment.
Your treatment for lung cancer will be customized to your particular needs. It may include one or more of the following therapies to treat the cancer and help relieve symptoms.
Surgery
Surgery may be a good option for those with early-stage non-small cell lung cancer. In some cases, patients may receive chemotherapy or radiation before surgery to shrink the tumor. This is called neoadjuvant therapy.
The most common types of surgery for lung cancer, in order of the amount of lung tissue removed, are:
- Wedge resection: Removal of the tumor and a pie- or wedge-shaped piece of the lung around the tumor. This procedure is typically used to perform a biopsy of a lung nodule.
- Segmentectomy or segmental resection: Removal of a segment, or part, of the lobe where the cancer is located. Both the segmentectomy and wedge resection are typically performed on patients who have limited lung capacity and can’t tolerate the removal of a larger section of the lung. They are also a good option for patients with small early-stage tumors generally measuring less than two centimeters. Both preserve lung capacity and the patient’s quality of life.
- Lobectomy: Removal of the lung lobe where the cancer is located. This is considered the “standard of care” for most lung cancer patients who undergo surgery.
- Sleeve lobectomy: A more complex form of lobectomy that is typically used for centrally located tumors. It involves removing the lobe where the tumor is located and part of the connecting bronchus. The cut bronchus is then connected with the remaining lobes. Though not always possible, sleeve lobectomies are preferable to pneumonectomy (complete removal of the lung) in order to preserve more functioning lung tissue.
- Pneumonectomy: Removal of an entire lung. This surgery is occasionally required due to the location of the tumor. In people with lungs that are otherwise healthy and function normally, pneumonectomy is well tolerated.
During most of these procedures, the surgeon will also remove lymph nodes from the chest. Since cancer often spreads through these nodes, doctors will examine them under a microscope to find out if the lung cancer has moved outside the lungs. This will help doctors decide if you need further treatment after surgery, such as chemotherapy, radiation therapy or targeted therapy. Treatment following surgery is called adjuvant therapy.
Surgical approaches
For some lung cancer surgeries, there are different ways to perform the same procedure. Your surgeon will work with you to choose the best option. These methods include:
- Open surgery: The traditional surgical method. Surgeons perform the procedure through a four- to eight-inch incision between the ribs.
- Minimally invasive surgery: These procedures require several smaller incisions, typically between ¼ and ½ inch, and usually have a shorter recovery time and less pain for the patient. There are two primary methods of minimally invasive surgery for lung cancer patients.
- Video-assisted thoracic surgery (VATS) or thoracoscopy: This technique uses a small camera and instruments that are inserted into the chest allowing the surgeon to perform the surgery through small incisions. It is typically performed on patients with small, early stage lung cancers.
- Robotic-assisted Surgery: This newer method of minimally invasive surgery uses robotic arms remotely controlled by the surgeon. Better images of the surgical site and greater instrument dexterity allow the surgeon to perform more complex surgery than is possible with VATS.
Statistically speaking, the more experienced the surgeon, the better the outcomes for lung cancer patients. MD Anderson’s Thoracic Center is home to many of the field’s most highly trained, experienced and respected thoracic surgeons. They operate only on cancers involving the chest and use the most advanced surgical techniques to treat a wide variety of lung cancers, including highly complex cases.
All patients with lung cancer who undergo surgery at the Thoracic Center enroll in a program of enhanced recovery, which aims to minimize pain, surgical stress and downtime. This leads to faster recovery, fewer side effects and better quality of life following surgery.
Radiation Therapy
Radiation therapy uses focused, high-energy photon beams to destroy lung cancer cells. It is performed by a radiation oncologist, a specialist who is specially trained to treat cancer with ionizing radiation. At most hospitals, radiation oncologists are expected to treat several different types of cancer. MD Anderson’s Thoracic Center has radiation oncologists dedicated exclusively to caring for patients with lung cancer. This gives them incredibly deep experience in designing treatment plans.
Working with these radiation oncologists is a team of radiation therapy specialists, including dosimetrists and medical physicists. Together, this team of experts develops models for several different treatment types and determines which is best for each patient. This way, MD Anderson can deliver the maximum amount of radiation with the least damage to healthy cells. The radiation therapy treatments used for lung cancer patients include:
- 3D-conformal radiation therapy: Several radiation beams are given in the exact shape of the tumor. This is primarily used as a palliative treatment and not to cure the disease.
- Brachytherapy: Tiny radioactive seeds are placed in the body close to the tumor. Brachytherapy is primarily used to treat metastatic growths in the airway. Since most of these growths can be treated with external beam radiation, brachytherapy is rarely used on lung cancer patients.
- Intensity-modulate radiotherapy (IMRT): Treatment is tailored to the specific shape of the tumor. This type of radiation is commonly used to treat cancers that have invaded nearby lymph nodes.
- Volumetric-modulate Arc therapy (VMAT): This is a special type of IMRT. In it, the part of the machine that shoots out the beam of radiation rotates around the patient in an arc. This can irradiate the tumor more precisely and shorten procedure times.
- Stereotactic body radiation therapy (SBRT): High doses of radiation delivered with several beams at various intensities and angles to precisely target the tumor. Learn more about SBRT.
Proton therapy
A type of radiation therapy, proton therapy delivers a high dose of radiation directly to the tumor, sparing nearby healthy tissue and organs. MD Anderson operates one of the world’s largest and most advanced proton therapy centers. Read more about proton therapy and how it is used to treat lung cancer.
Systemic Therapy
Systemic therapy is an umbrella term for treatments that use substances that travel through the bloodstream to reach affected cells all over the body. There have been significant advances in systemic therapy treatments for lung cancer over the last decades. The medical oncologists at MD Anderson’s Thoracic Center are world-renowned in the care of lung cancer patients and have participated in the clinical trials that have led to the development of important new treatments, including targeted and immune therapies.
Targeted therapy
Cancer cells use specific molecules (often in the form of proteins) to survive, multiply and spread. Targeted therapies stop or slow the growth of cancer by interfering with, or targeting, these molecules. Currently there are targeted therapies for many subtypes of adenocarcinoma. Read more about targeted therapies.
Immunotherapy
Immunotherapies recruit the body’s own immune system in the fight against cancer. The current standard of care for non-small cell lung cancer includes the use of checkpoint inhibitor immunotherapies, which take the natural “brakes” off the immune system, allowing it to attack cancer cells. This treatment can lead to durable responses and has revolutionized care for lung cancer patients. Read more about immunotherapy.
Chemotherapy
Chemotherapy uses drugs to directly kill cancer cells by stopping their growth. This form of treatment is commonly combined with immunotherapy. In combination, both drugs become more effective. Learn more about chemotherapy.
Angiogenesis inhibitors
Angiogenesis is the process of creating new blood vessels. Vascular endothelial growth factor (VEGF) is one of the main molecules that control the process. Some cancerous tumors are very efficient at using these molecules to create new blood vessels, which increases blood supply to the tumor and allows it to grow more rapidly.
Researchers developed drugs called angiogenesis inhibitors, or anti-angiogenic therapy, to disrupt the growth process. These drugs search out and bind themselves to VEGF molecules or receptor proteins, prohibiting them from activating angiogenesis.
Learn more about lung cancer:
In some cases, lung cancer can be passed down from one generation to the next. Genetic counseling may be right for you. Visit our family history site to learn more about genetic counseling and testing.
MD Anderson lung cancer patients can get treatment at the following locations.
4 advances in radiation therapy for lung cancer treatment
One of the most difficult aspects of treating lung cancer with radiation therapy is determining the best way to deliver it. Ideally, doctors want to provide the most effective dose to a tumor while limiting exposure to healthy adjacent organs, tissues and structures.
The challenge with lungs is that they’re always in motion. This can make it difficult to keep radiation focused directly on tumors.
“Right now, we have to ask patients to hold their breath during treatment to minimize movement,” says radiation oncologist Zhongxing Liao, M.D.
That can make it tricky to protect critical organs, such as the heart, liver — and even unaffected sections of the lungs.
Fortunately, all of that is changing. Here’s how.
Next-generation technologies include real-time motion management
Next-generation technologies are enabling physicians to shield healthy tissues more effectively. By using machines that can scan patients during their treatment sessions, radiation oncologists are able to make real-time adjustments to accommodate patients’ movements.
“The technology of radiation therapy is evolving every day,” says Liao. “We went from simple X-ray films in the early 1990s to cutting-edge, on-board imaging in the 2010s. Now, we’re building our second-generation proton therapy machine, which will use respiratory motion management and real-time tracking to monitor each patient’s position.”
Combination cancer treatments becoming standard of care
Other recent advances in radiation therapy for lung cancer include stereotactic ablative radiation therapy (SABR) and stereotactic body radiation therapy (SBRT). Both deliver super-high-dose radiation to small targets in a very short period of time — usually four to 10 treatments within one to two weeks.
“That makes them very effective at killing cancer cells,” Liao says. “It also makes them comparable to surgery in terms of their ability to successfully eliminate some cancers.”
Proton therapy can be a good option for many patients, too, because of its unique depth-dose characteristics. And combining radiation therapy with other treatments (such as chemotherapy, immunotherapy, and targeted therapy) has proven so effective that chemotherapy plus radiation therapy and immunotherapy is now considered the standard of care for patients with locally advanced lung cancers.
“Proton therapy is especially useful when tumors are located next to the heart,” adds Liao. “It’s also good at treating solid tumors, because those have enough mass to prevent its radiation from passing through them.”
Options for both treating lung cancer and limiting its progression
Radiation therapy is often used in early-stage lung cancer patients who cannot — or choose not to — have surgery. But radiation therapy can also limit disease progression in patients with more advanced lung cancers.
“MD Anderson has some of the most advanced radiation technology available,” Liao says. “So, we have treatment options for patients in every stage of lung cancer.”
Protecting patients from unnecessary radiation exposure
To prevent damage to healthy structures from excess radiation exposure during lung cancer treatment, MD Anderson has established dose constraints for every organ located in or near the chest cavity, such as the heart, liver and esophagus.
“We set our bar very high to make sure critical organs are well-protected,” says Liao. “Every tumor is unique, so we evaluate each treatment plan before therapy starts to determine which radiation therapy technology best fits the needs of the patient.”
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Ommaya reservoir and its role in cancer care
An Ommaya reservoir is a plastic, dome-shaped device inserted underneath the skin on your scalp. The dome is connected to a catheter placed in the ventricle of your brain where the cerebrospinal fluid (CSF) circulates.
Doctors often use Ommaya reservoirs in patients with leptomeningeal disease (LMD), specifically solid tumor LMDs, such as breast cancer, lung cancer and melanoma.
To learn about Ommaya reservoirs and how they’re used in cancer treatment, we tapped the experts: neuro-oncologist Barbara O’Brien, M.D., and neurosurgeon Jeffrey Weinberg, M.D.
What is the purpose of an Ommaya reservoir?
Doctors can use an Ommaya reservoir to inject medicine into the fluid around your brain and spinal cord or aspirate the fluid for testing.
LMD occurs when cancer cells from primary tumors enter the CSF or leptomeninges, the inner lining of the brain and spinal cord. Cancer patients who develop LMD may receive intrathecal chemotherapy as part of their treatment.
“An Ommaya can be placed to allow the delivery of chemotherapy directly to the cerebrospinal space. Doing so allows us to bypass the blood-brain barrier,” says O’Brien. “It can be a more effective, direct way of delivering chemo to some patients with LMD.”
How is an Ommaya reservoir placed?
An Ommaya reservoir is placed by a neurosurgeon while you’re under general anesthesia.
“After the patient is asleep, we can use a stereotactic navigation system to select the location to guide the catheter into the patient’s ventricle,” says Weinberg.
The surgeon makes a large, C-shaped incision in the scalp and drills a small hole in the skull.
“We intentionally make the incision big because we cut all the nerves that bring pain to the flap overlying the dome,” explains Weinberg.
This means the patient will feel no pain any time chemotherapy is injected into the dome.
“We make a small nick in the brain tissue and then use the navigation system to guide the catheter through the hole we drilled and into the ventricle,” explains Weinberg. “Once it’s in the ventricle, we test to make sure we’re getting CSF flowing freely from the catheter.”
The Ommaya reservoir is secured with sutures to ensure it stays in place. The procedure typically takes 20 to 40 minutes.
Doctors will take a CT scan after the procedure to make sure the tip of the catheter is in the correct location and there’s no bleeding. Patients stay in the hospital overnight. If there are no issues, you can go home the following morning.
How do you care for an Ommaya reservoir after placement?
The most important thing is to make sure the wound heals properly.
“We don’t want the wound to get infected, so you must allow it to heal. That can take anywhere from 10 to 14 days,” says Weinberg. “Even then, the wound is still delicate, so make sure not to scratch or pick at it. You can exercise, but swimming is not recommended. It’s best to avoid contact sports for about a month following surgery.”
Check with your doctor to see when you can resume normal activities.
Are there any risks associated with an Ommaya reservoir?
Risks can include:
Wrong location
If the Ommaya reservoir is placed or ends up in the wrong location, you must see a neurosurgeon to get it repositioned.
Bleeding
If there’s a small amount of blood visible on a scan, your doctors may monitor for additional bleeding and do another CT scan. If bleeding is significant, you’ll need surgery to have the blood clot removed. This is extremely rare.
Infection
If the wound gets infected, you will need surgery to have the Ommaya reservoir removed.
How is an Ommaya reservoir used in leptomeningeal disease treatment?
MD Anderson’s Brain and Spine Center offers an Ommaya clinic for patients on Mondays and Thursdays. LMD patients with Ommaya reservoirs usually begin receiving chemotherapy twice a week.
When a patient visits the clinic, a neuro-oncology advanced practice provider (APP) cleans and sterilizes the area on the head. Then the provider inserts a needle into the reservoir and removes a small amount of fluid. This is known as an Ommaya reservoir tap.
“The fluid is sent to the lab for testing, and some of the fluid is earmarked for research if the patient has consented to a research study,” says O’Brien. “After the fluid is withdrawn, the provider injects chemo into the Ommaya reservoir.”
CSF cytology identifies cancerous cells in the fluid and helps doctors assess how well patients are responding to treatment. Research testing helps doctors learn more about the underlying biology of LMD, in part by assessing the molecular profile of the tumor.
Some patients may experience headaches, neck pain or nausea after the procedure. Doctors work with patients to manage these symptoms by adjusting the amount of fluid taken or prescribing steroids to reduce inflammation that may occur from injecting chemo.
“Patients typically follow up with their neuro-oncologist every four weeks while on treatment, and we reassess with imaging of the brain and spine every eight weeks to make sure the treatment is effective,” says O’Brien. “At eight weeks, if the treatment is working and all parameters look good, we consider decreasing the frequency of the Ommaya reservoir taps. It may go from twice a week to once a week or from once a week to every other week.”
Is an Ommaya reservoir the same as a shunt?
No. A shunt is commonly used in patients who have a blockage in their CSF pathway, causing fluid to accumulate in the brain.
“We will surgically place a shunt in the brain to help drain excess cerebrospinal fluid from the brain and transport it to another part of the body, where it gets reabsorbed back into the bloodstream,” says Weinberg. “The Ommaya reservoir – while we can attach a shunt to it, if necessary – is specifically placed to be used only when needed. There’s no continuous draining of fluid.”
How do you determine who is a good candidate for an Ommaya reservoir?
An LMD patient may have an Ommaya reservoir placed if doctors determine intrathecal chemotherapy is the best way to treat the disease. But it isn’t right for everyone.
“For instance, intrathecal chemotherapy only penetrates a few millimeters, so this therapy is not expected to help patients who have bulky or nodular LMD,” says O’Brien.
She carefully reviews the imaging to determine if the type of LMD the patient has can be appropriately treated by intrathecal chemo.
“If a patient functions well, doesn’t have any significant neurologic symptoms and has options to treat any active cancer outside of their leptomeninges, then they may be a good candidate for intrathecal chemotherapy via an Ommaya reservoir,” she says.
The goal of intrathecal chemo is to keep LMD under control, not manage symptoms. It’s important to have honest, realistic conversations with your doctors about your goals. Some patients want doctors to do whatever’s possible to help them make it to a special milestone in their lives. Other patients place more importance on quality of life and do not want to travel back and forth to a clinic twice a week to receive chemo.
“LMD can be tough to treat, so we must consider our options carefully,” says O’Brien. “A nice thing about intrathecal chemotherapy is it only treats the leptomeningeal compartment, so patients can often continue receiving systemic therapy without concerns of their treatments interfering with one another.”
Request an appointment at MD Anderson online or call 1-877-632-6789.